Quality and safety education for nurses

Quality and safety education for nurses

Linda Cronenwett, PhD, RN, FAAN Gwen Sherwood, PhD, RN, FAAN Jane Barnsteiner, PhD, RN, FAAN Joanne Disch, PhD, RN, FAAN Jean Johnson, PhD, RN-C, FAAN Pamela Mitchell, PhD, CNRN, FAAN Dori Taylor Sullivan, PhD, RN, CNA, CPHQ

Judith Warren, PhD, RN, BC, FAAN, FACMI 

Quality and Safety Education for Nurses (QSEN) ad- dresses the challenge of preparing nurses with the competencies necessary to continuously improve the quality and safety of the health care systems in which they work. The QSEN faculty members adapted the Institute of Medicine1 competencies for nursing (patient-centered care, teamwork and col- laboration, evidence-based practice, quality im- provement, safety, and informatics), proposing defi- nitions that could describe essential features of what it means to be a competent and respected nurse. Using the competency definitions, the authors propose statements of the knowledge, skills, and attitudes (KSAs) for each competency that should be devel- oped during pre-licensure nursing education. Quality and Safety Education for Nurses (QSEN) faculty and advisory board members invite the profession to com- ment on the competencies and their definitions and

Linda Cronenwett is a Professor and Dean at the School of Nursing, University of North Carolina at Chapel Hill. Gwen Sherwood is a Professor and Associate Dean for Academic Affairs at the School of Nursing, University of North Carolina at Chapel Hill. Jane Barnsteiner is a Professor and Director of Translational Research at the School of Nursing and Hospital of the University of Pennysylvania, Philadelphia, PA. Joanne Disch is Kathyrn R. and C. Walton Lillehei Professor and Director of the Densford International Center for Nursing Leadership at the School of Nursing, University of Minnesota, Minneapolis, MN. Jean Johnson is a Professor and Senior Associate Dean for Health Sciences at The George Washington University, Washington, DC. Pamela Mitchell is Elizabeth S. Soule Professor and Associate Dean for Research at the School of Nursing, University of Washington, Seattle, WA. Dori Taylor Sullivan is an Associate Professor and Chair, Department of Nursing at Sacred Heart University, Fairfield, CT. Judith Warren is an Associate Professor at the University of Kansas School of Nursing and Director of Nursing Informatics at Kansas University Center for Healthcare Informatics, Kansas City, KS. Reprint requests: Linda Cronenwett, PhD, RN, FAAN, Dean and Professor, School of Nursing, University of North Carolina at Chapel Hill, Carrington Hall, CB #7460, Chapel Hill, NC 27599-7460. E-mail: lcronenwett@unc.edu

Nurs Outlook 2007;55:122-131. 0029-6554/07/$–see front matter Copyright © 2007 Mosby, Inc. All rights reserved.


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on whether the KSAs for pre-licensure education are appropriate goals for students preparing for basic practice as a registered nurse.

A series of national commissions have documentedsignificant problems related to safety and quality inthe US health care system.1–5 In light of these problems, reports from multiple national committees con- cluded that if health care is to improve, providers need to be prepared with a different set of competencies than are developed in educational programs today.1,6 Health pro- fessionals, using scientific evidence, need to be able to describe what constitutes good care, identify gaps between good care and the local care provided in their practices, and know what activities they could initiate, if necessary, to close any gaps.7 Faculties of medicine, nursing, and other health professions are challenged by the 2003 Institute of Medicine (IOM) Health Professions Education report1 to mindfully alter learning experiences that form the basis for professional identity formation so that grad- uates are educated to deliver patient-centered care as members of an interdisciplinary team, emphasizing evidence-based practice, quality improvement approaches, and informatics.1

Will, ideas, and execution are required to incorporate the development of the above competencies in nursing education. Unlike medicine, where commitment to an adapted version of the IOM competencies is now in place for the continuum from medical school to resi- dency program to certification,8,9 nursing has no con- sensus on the competencies that could apply to all nurses—that would define what it means to be a respected and qualified nurse. At the core of nursing, however, lies incredible historical will to ensure quality and safety for patients. Evidence of valuing quality and safety competencies in nursing is evident in nursing publications,10–12 standards of practice,13 and accredi- tation guidelines.14,15 The American Association of Colleges of Nursing Task Force on the Essential

Patient Safety Competencies for Professional Nurs- 




Quality and safety education for nurses Cronenwett et al

Table 1. Patient-centered Care

Definition: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for patient’s preferences, values, and needs.

Knowledge Skills Attitudes

Integrate understanding of multiple dimensions of patient-centered care:

● patient/family/community preferences, values

● coordination and integration of care

● information, communication, and education

● physical comfort and emotional support

● involvement of family and friends ● transition and continuity

Elicit patient values, preferences and expressed needs as part of clinical interview, implementation of care plan and evaluation of care

Communicate patient values, preferences and expressed needs to other members of health care team

Provide patient-centered care with sensitivity and respect for the diversity of human experience

Value seeing health care situations “through patients’ eyes”

Respect and encourage individual expression of patient values, preferences and expressed needs

Value the patient’s expertise with own health and symptoms

Seek learning opportunities with patients who represent all aspects of human diversity

Describe how diverse cultural, ethnic, and social backgrounds function as sources of patient, family, and community values

Recognize personally held attitudes about working with patients from different ethnic, cultural and social backgrounds

Willingly support patient- centered care for individuals and groups whose values differ from own

Demonstrate comprehensive understanding of the concepts of pain and suffering, including physiologic models of pain and comfort

Assess presence and extent of pain and suffering

Assess levels of physical and emotional comfort

Elicit expectations of patient & family for relief of pain, discomfort, or suffering

Initiate effective treatments to relieve pain and suffering in light of patient values, preferences, and expressed needs

Recognize personally held values and beliefs about the management of pain or suffering

Appreciate the role of the nurse in relief of all types and sources of pain or suffering

Recognize that patient expectations influence outcomes in management of pain or suffering

Examine how the safety, quality, and cost-effectiveness of health care can be improved through the active involvement of patients and families

Examine common barriers to active involvement of patients in their own health care processes

Describe strategies to empower patients or families in all aspects of the health care process

Remove barriers to presence of families and other designated surrogates based on patient preferences

Assess level of patient’s decisional conflict and provide access to resources

Engage patients or designated surrogates in active partnerships that promote health, safety and well-being,

Value active partnership with patients or designated surrogates in planning, implementation, and evaluation of care

Respect patient preferences for degree of active engagement in care process

Respect patient’s right to access to personal health records

and self-care management

123M A Y / J U N E N U R S I N G O U T L O O K



in car

Quality and safety education for nurses Cronenwett et al

ing Care recently completed an enhancement to the Essentials of Baccalaureate Education for Profes- sional Nursing Practice to include exemplars of qual- ity and safety competencies.16 But the ideas for what to teach, how to teach, and how to assess learning of the competencies are sorely lacking, and there are few, if any, examples of schools claiming to execute a com- prehensive quality and safety curriculum.

DEFINING THE COMPETENCIES Quality and Safety Education for Nurses (QSEN), funded by the Robert Wood Johnson Foundation, was designed to address these gaps—to build on the will, to develop the ideas, and to facilitate execution of changes in nursing education. Before teaching strategies could be developed, however, the QSEN faculty needed to identify specifically what was to be achieved. Working with an Advisory Board of thought leaders in nursing and medicine (see acknowledgments), the authors re- viewed the relevant literatures and adapted the IOM1

competencies for nursing. The goal was to describe competencies that would apply to all registered nurses.

In Tables 1–6, the definitions are shared with the profession with the hope that nursing, through its professional organizations, can benefit from the work. If nursing constituencies find these competency defini- tions clear and compelling, over time the competencies can serve as guides to curricular development for

Table 1. Continued

Definition: Recognize the patient or designee a compassionate and coordinated care based on


Explore ethical and legal implications of patient-centered care

Describe the limits and boundaries of therapeutic patient-centered care

Recognize t therapeut

Facilitate inf consent fo

Discuss principles of effective communication

Describe basic principles of consensus building and conflict resolution

Examine nursing roles in assuring coordination, integration, and continuity of care

Assess own communic encounte families

Participate i or resolvin context o

Communica and need transition

formal academic programs, transition to practice, and

124 V O L U M E 5 5 ● N U M B E R 3 N U R S I N G O U

continuing education programs. In addition, the defini- tions can provide a framework for regulatory bodies that set standards for licensure, certification, and ac- creditation of nursing education programs.

PRE-LICENSURE NURSING EDUCATION The competency definitions provided a broad frame- work for QSEN’s work to define pedagogical strategies for quality and safety education; however, as is evident in the accompanying article in this issue, when the competency names and definitions were used alone, the vast majority of pre-licensure program leaders stated that they already included content related to the com- petencies in their curricula.17 Relying on the respondent to interpret the general definitions of the QSEN com- petencies, levels of satisfaction with the extent to which students developed these competencies were high, and program leaders believed that faculty possessed the necessary expertise to teach these competencies.

The QSEN faculty and advisory board members did not share the view that pre-licensure nursing students were graduating with these competencies. We knew that many students graduated without ever communi- cating a recommendation for a change in patient care to a physician. Many of us knew that students learned the “five rights” of medication administration but lacked the language of common concepts related to safety

source of control and full partner in providing ct for patient’s preferences, values, and needs.

ls Attitudes

undaries of tionships

d patient e

Acknowledge the tension that may exist between patient rights and the organizational responsibility for professional, ethical care

Appreciate shared decision- making with empowered patients and families, even when conflicts occur

f skill in patients and

ding consensus flict in the nt care

re provided each


Value continuous improvement of own communication and conflict resolution skills

s the respe


he bo ic rela

orme r car

level o ation

rs with

n buil g con f patie

te ca ed at

sciences or quality improvement methods. With the




Quality and safety education for nurses Cronenwett et al

Table 2. Teamwork and Collaboration

Definition: Function effectively within nursing and inter-professional teams, fostering open communication, mutual respect, and shared decision-making to achieve quality patient care.

Knowledge Skills Attitudes

Describe own strengths, limitations, and values in functioning as a member of a team

Demonstrate awareness of own strengths and limitations as a team member

Initiate plan for self-development as a team member

Act with integrity, consistency and respect for differing views

Acknowledge own potential to contribute to effective team functioning

Appreciate importance of intra- and inter-professional collaboration

Describe scopes of practice and roles of health care team members

Describe strategies for identifying and managing overlaps in team member roles and accountabilities

Recognize contributions of other individuals and groups in helping patient/family achieve health goals

Function competently within own scope of practice as a member of the health care team

Assume role of team member or leader based on the situation

Initiate requests for help when appropriate to situation

Clarify roles and accountabilities under conditions of potential overlap in team-member functioning

Integrate the contributions of others who play a role in helping patient/family achieve health goals

Value the perspectives and expertise of all health team members

Respect the centrality of the patient/family as core members of any health care team

Respect the unique attributes that members bring to a team, including variations in professional orientations and accountabilities

Analyze differences in communication style preferences among patients and families, nurses, and other members of the health team

Describe impact of own communication style on others

Discuss effective strategies for communicating and resolving conflict

Communicate with team members, adapting own style of communicating to needs of the team and situation

Demonstrate commitment to team goals

Solicit input from other team members to improve individual, as well as team, performance

Initiate actions to resolve conflict

Value teamwork and the relationships upon which it is based

Value different styles of communication used by patients, families, and health care providers

Contribute to resolution of conflict and disagreement

Describe examples of the impact of team functioning on safety and quality of care

Explain how authority gradients influence teamwork and patient safety

Follow communication practices that minimize risks associated with handoffs among providers and across transitions in care

Assert own position/perspective in discussions about patient care

Choose communication styles that diminish the risks associated with authority gradients among team members

Appreciate the risks associated with handoffs among providers and across transitions in care

Identify system barriers and facilitators of effective team functioning

Examine strategies for improving systems to support team

Participate in designing systems that support effective teamwork

Value the influence of system solutions in achieving effective team functioning


125M A Y / J U N E N U R S I N G O U T L O O K



Quality and safety education for nurses Cronenwett et al

goal of clarifying rather than prescribing current mean- ings of the competency definitions, we outlined the knowledge, skills, and attitudes (KSAs) appropriate for pre-licensure education.

During 2 workshops and multiple email communica- tions, the authors led the process of KSA development. We focused on all of pre-licensure education (associate, diploma, baccalaureate, and master’s entry), because the ultimate goal is to assure that all patients will be cared for by nurses who have developed the KSAs for each com- petency. We tried to answer the question, “What should nursing promise with regards to its pre-licensure gradu- ates’ quality and safety education?”

At each step, we sought feedback from nursing faculty.

Table 3. Evidence-based Practice (E

Definition: Integrate best current evidence wit and values for delive


Demonstrate knowledge of basic scientific methods and processes

Describe EBP to include the components of research evidence, clinical expertise and patient/family values

Participate appropri other res

Adhere to (IRB) guid

Base individ patient v and evid

Differentiate clinical opinion from research and evidence summaries

Describe reliable sources for locating evidence reports and clinical practice guidelines

Read origin evidence of practi

Locate evi clinical p guideline

Explain the role of evidence in determining best clinical practice

Describe how the strength and relevance of available evidence influences the choice of interventions in provision of patient-centered care

Participate environm integratio standard

Question ra approac less-than adverse

Discriminate between valid and invalid reasons for modifying evidence-based clinical practice based on clinical expertise or patient/family preferences

Consult wit deciding evidence

In contrast to the results of the survey, when nursing

126 V O L U M E 5 5 ● N U M B E R 3 N U R S I N G O U

school faculty from 16 universities in the Institute for Healthcare Improvement Health Professions Education Collaborative reviewed the KSA publish, they uniformly reported that nursing students were not developing these KSAs. Additional focus groups were held with faculty who taught pre-licensure students in QSEN faculty mem- bers’ schools, and the responses were the same. Although the faculty agreed that they should be teaching these competencies and, in fact, had thought they were, focus group participants did not understand fundamental con- cepts related to the competencies and could not identify pedagogical strategies in use for teaching the KSAs.

A chief nurse executive serving on the QSEN advi- sory board led a focus group of new graduates. Not only

ical expertise and patient/family preferences optimal health care.

Skills Attitudes

tively in ata collection and


tional Review Board s

ed care plan on , clinical expertise

Appreciate strengths and weaknesses of scientific bases for practice

Value the need for ethical conduct of research and quality improvement

Value the concept of EBP as integral to determining best clinical practice

search and rts related to area

e reports related to e topics and

Appreciate the importance of regularly reading relevant professional journals

ucturing the work o facilitate new evidence into ractice

le for routine care that result in

ed outcomes or s

Value the need for continuous improvement in clinical practice based on new knowledge

ical experts before viate from d protocols

Acknowledge own limitations in knowledge and clinical expertise before determining when to deviate from evidence-based best practices

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